EMSSA Day 1 review. Co-created review with St.Emlyn’s.

So that’s the end of day 1 here at Sun City. This is EMS day and so we have a number of streams addressing the world of prehospital, emergency department and critical care. As ever you can’t get to everything so apologies to those we have missed from the review. Here’s the notes from day 1, co-created with a great team of delegates. For more on co-creation skip to the bottom of the post (it’s a great way of putting conference reports together).

Be warned, this is a long post as there is a lot of content from some great speakers.

The future of EMS in South Africa
First up Christopher Stein talked about a possible future for EMS. It was Blade Runner-esque with a vision of an EMS system based on apps, technology and machine learning. A world where technology will make the key decisions of who, when and why people may interact with EMS systems. This theme fits with other talks we’ve seen at other conferences. I (Simon) talked about this at SMACC in Dublin and Bryan Burns and friends demonstrated this with an amazing demo at SMACC in Berlin.

Chris Stein: We have to embrace change in EMS – disaster is looming if we don't. #EMSSA2017

This talk was a little differnet to past talks on the future of emergency care though. Whilst others have talked about technology enhancing current systems Christopher took the perspective of a system that is already challenged, and which is likely to become more challenged, overwhelmed even. Change has to happen.

Elon Musk “Some people don’t like change, but you need to embrace change if the alternative is disaster.”

Elon Musk: If something is important enough you should try, even if the probable outcome is failure.

Shaheen took this on and talked about why SA might have adopted a US model for EMS which may not be suitable for the African setting. It’s not always about saving lives, it’s mostly about transportation and logistics. So this raises questions about what we are teaching in the EMS education. We don’t seem to get complaints about clinical care, but we do get complaints about being late, being rude, being unavailable. Those are logistics issues which is interesting. It’s not our personal image of being an EMS/EM provider. Perhaps we need to wake up and really embrace the patient perspective of the service as a whole and not just focus on the coll resuscitation stuff.

Chris Stein: We have to embrace change in EMS – disaster is looming if we don't. #EMSSA2017

This was very much a thoughtful presentation about what we are really trying to achieve in EMS in Africa. Simply transplanting a US/European/Aus model of care may not be the right thing to do. A talk with more questions than answer, but REALLY important questions. To take the Blade Runner analogy further, EMS in SA cannot be a replicant of something else. Christopher and Shaheen propose a consensus conference to get interested parties together to create a shared vision for SA EMS.

Starting with an incredibly powerful video on the problems of violence against paramedics. He talks through the experience of responding to a call when one of his paramedics was shot. Is the solution tactical paramedics? Should we arm paramedics and turn them into SWAT teams? Craig argues not. It’s not possible to do and probably unsustainable. Even police escorted ambulances are at risk, they might be attacked even if protected by armed police.

So what can be done? Clearly we can’t do nothing. EMS personel are at risk and need protection.

Chris and Craig

One solution is to work with the police, to train with the police to become more situationally aware about any circumstance they might find themselves in. Petrol bombs, bullets, hijacking etc. All are covered in the curriculum with the intention of not turning EMS into SWAT teams, but rather to work with the police to understand what to do when work turns ugly.Then there is the community. Both Craig and delegates talked about the power of community to protect EMS personnel. Communities with strong leadership who don’t accept violence against EMS will always be more able to help protect. Far more powerful than any course or training package.

Craig also talked about the idea of areas where EMS cannot enter because it’s simply too dangerous. Truly a terrifying vision for a Brit like me, and a real eye opener about delivering high quality care under exceptionally difficult circumstances.

Non-Invasive Ventilation
Willem Stassen compared non-invasive ventilation to the avocado. Summary on the indications, contraindications and best options for the use of non-invasive ventilation “there are two types of people in the world, those who like avocados, and those who should”, the same applies to non-invasive ventilation”

Pearls for initiating NIV:Monitoring must be available (at least SPO2 and if possible ABG)Haemodynamics must be intact (or at least there must be some effort to managing perfusion prior to initiating)NIV is a good bridge to intubation (especially in the neonatal population)

Dont use NIV In the apneic patient (or the dead patient)Life threatening hypoxia (close to a crash airway where there is not time to set up the NIV) Upper airway issuesUndrained tension pnuemothoraxBowel obstruction

Willem made it clear that the value of NIV in the pre-hospital setting for the right patient at the right time in the right condition.
The systems approach to the application of NIV is vital, the drop off site and optimising of care in the receiving facility must be a system of care, education, resources and equipment must be present within the whole system to support the ongoing management of the patient.

Pre-hospital Analgesia
Took us back to basics with the physiology of pain and why pain is so important in emergency care. At the bedside, the physiology becomes a bit more simple.

To answer better pain management in the prehospital environemnt, this was broken down into 3 major thought processes:Nociceptive (the place where the pain is initially felt, also called inflammatory soup)Perception (in the brain)Neuropathic (how the sensation is integrated)

Acute events that couse pain, quite commonly leads to chronic pain, this means we need to pay attention to the way in which acute pain is managed to prevent the progression to chronic pain later. If the pain is not managed AGGRESSIVLY and early in the pre-hospital setting, the risk of development of chronic pain increases. Chronic pain is a multi-system stress response mediated by cortisol. Chronic pain has long term cognitive and psychological effects (commonly PTSD).

Step-wise approach to pain management
There is no ONE agent that is best for any particular pain, the approach is about preventing transition to chronic pain
Multi-modal approach to pain management (allows decreased doses of each agent)Options for pre-hospital pain management in SA is limited… more agents needed to address the multi-modal approach to pain management.

Other options for perception of painFentanylKetamineEntonoxMorphineMethoxyfluraneBenzodiazepines

In SA pain medications for pre-hospital use are only allowed for specific indications, this is mandated by law.

Barriers to better pain management?Education and training (changing curriculum to accommodate new information)Willingness to change (fear of changing the way we do things)Clinical governance and monitoring systemRegulatory control (system and provider perspective)Public participation and input (as well as patient education)Cost (to get access to medication that is costly)Continuity of care (continuum of analgesia through the multiple systems of care)

The failing heart
Dr Jacques Malan on the failing heart. This kicked off with some amazing videos of acute heart failure management in the ED. All with patient’s permissions as stated at the conference.

Lots on managing HF in the ED, but started with the really important point that the ED can be a point of intervention for public health interventions. Check the BP of your patients and look at any ECG for any signs of LVH. If you do find hypertension then don’t just ignore it. Look for causes as if it’s secondary hypertension you can perhaps make a life changing intervention. At St.Emlyn’s we totally agree that public health is something that we should do.

For those patients who do turn up in the ED with symptoms of heart failure than POCUS ECHO is a really effective tool to discriminate between causes and severities. Many patients might get wheeled into the ED with signs and symptoms that might not obviously be heart failure. Beware the young patient wheeled into the ED on a nebuliser who just does not look right, without wheeze or fever. Jacques asks us to be Sherlock in such cases. Feel the peripheries, are they warm or cool, get a CXR, get an ECG and really look at it for signs of chronic heart failure/hypertension etc.

Jacques went on to talk about specific heart failure management and I liked what I heard in that he advocates a strategy aimed at the particular patient in front of you. There is no one size fits all recipe for acute heart failure. Be clever, be wise and be specific, in essence and in Jacque’s words ‘don’t fail the heart’.

5 ECG diagnoses not to miss

Kamil Vallabh whom I met early this year talked on 5 ECG diagnoses not to miss. This guy is a legend. An incredible clinician and ECG guru.

Abnormal morphology matters even if the ST elevation does not meet criteria. This is especially significant if you have odd looking morphology with T wave inversion in aVL. Look at aVL and check for T-wave inversion. Example here on Steve Smith’s blog.

I think Kamil’s talk is really important if we are to think about what difference an EM consultant makes. There is little added value in spotting barn door diagnoses, what matters is spotting the subtle and the difficult. That’s where we can really make a difference.

This talk encouraged us to ask, “is there a reason NOT to do an ECG?”. If not, then the patient should get one. They are done automatically at triage by HCAs on almost every majors patient I see in the UK, but at my current South African hospital doing ECGs is doctors job, and it can be hard to find a private space to do them. Having said that, it being hard work is not a valid reason not to do one!

Resilience is a hot topic in emergency care at the moment. Tim took us back to the reasons why we started in medicine, often they were altruistic, empathic and caring. Yet the reality of medicine may be different. Many docs lose their empathy, many nurses leave in the first year, and here in South Africa there are high rates of burnout in EMS teams.

Tim talks honestly about the sense of detachment that can come with facing the challenges of trauma and acute care. Detachment may be a tool, but is it a healthy and compassionate one?

Tim claims he is a clown(he’s so much more– just look here), taking us through an exercise in creating laughter in the room. You could feel the room lift and get interested. Mood matters when you want to educate people, and also when you want to engage with patients. As a paeds nurse he has worked across the globe, including in the Ebola response in West Africa.

https://twitter.com/Kylz13/status/915141443395706880

In West Africa he found himself detached from the extreme situation he found himself in. It caused him to reflect on hpw we normalise the circumstances we find ourselves in, how that normalisation might pull us away from the compassion that was so important when we originally chose our career path. Why is then that we don’t train for compassion? Why don’t we plan for and understand how we might retain the compassion and empathy (maybe empathy – they are not the same) that is so important to improving the qualirty of health care.

Tim advocates that yoga and meditation can improve compassion which links to Scott Weingart’s talk at SMACC. Having said that, meditation and yoga takes time and we are busy people.

https://twitter.com/Kylz13/status/915145609388204032

I do understand this idea as the end of a resus is a strange time, a slightly odd set of circumstances before we are expected to move on. I guess this won’t be for everyone, but that’s not the point, If it’s important for some of the team, then it’s something the team should support. Marking a moment in time and the deceased persons life might help us move on to the next pateint and problem. I also think that if the family are present it might be incredibly important for them. Tim makes the point that this is not a religious act (although it could be if that’s your belief), it is arguably just as relevant to a humanist view.

This talk has certainly made me pause and reflect on how we manage the end of resuscitations when they are not successful. This is not debriefing, it’s respect. It’s free, it’s quick, it’s kind and may help a whole range of people. Tim’s talk begs the question – why wouldn’t you pause?

David Stanton on the extinction of the dinosaur.
David is an EMS director in South Africa for Netcare. The aim of this talk was to consider why there are fewer older paramedics here in SA? These are the dinosaurs that are missing, some have gone abroad (notably the Middle East), some have left EMS, others have moved into more 9-5 jobs. However, acute work stress and burnout appears to be a real problem amongst SA paramedics. Recent studies state that it’s up to 25% of EMS providers are burned out and leaving.

So what needs to be done? We need to think about different career paths, change the end game from retirement to portfolio careers. To support older EMS staff to retrain and requalify so that they can have adaptable and agile careers.

TIm also talks about the advances in technology that might be leaving some people behind. Interestingly he talks about how the new generation of learners are technology users who are trying to connect, rather than being driven by the tech itself. I agree withthis as an intpretation of us being in the social age as described by Julian Stodd.

Although clearly aimed at SA EMS teams, the thoughts and ideas here are probably applicable to many other countries and specilaities.

Sepsis care with Willem Stassen
Theme for this talk was really about applying Sepsis 3.0 in a pragmatic way, to allow for best outcome in the pre-hospital environment. No avocado’s in this talk 🙂

The major message through this talk was early recognition and early management for the patient who presents with sepsis (or possible sepsis). The challenges around use of sepsis screening tools in the pre-hospital environment (or even resources limited settings) were discussed and explained.

Sepsis can possibly be identified at the dispatch interface, understanding that the low resource setting, identification of sepsis on dispatch might assist with sending the correct vehicle and resources to the correct patient at the correct time. The themes around dispatch information and sepsis recognition are too broad to enable the specific diagnosis of sepsis on the phone. In SA language is a real challenge, with 11 official languages, and not all fluent in medicine or a common language.

We can attempt to adopt the some of the international guidelines, but sepsis in SA is very different.

Summary:
Suspect sepsis always
SA sepsis may not be the same as international cases, and descriptions are different
Recognition is the missing link

MUTI in Children with Dr Tim De Maayer (Paediatric Gastroenterologist Rahima Moosa Mother and Child Hospital in SA)

“Muti” is the colloquial term for traditional medication in South Africa. There are 3.6 traditional healers for every 1000 patients in SA, while Western Medicine doctors run at 0.8 doctors per 1000 patients. It is reported that approximately 60% of people in an urban SA setting in JHB that traditional healers were consulted prior to accessing public health.

60% of children seen in an urban South African outpatient department had been taken to a traditional healer first. #EMSSA2017

“Sangoma” is one of the terms for traditional healers within South Africa and commonly seen as a spiritual practice, which makes the system difficult to regulate. Access to these healers is available online even, making it incredibly difficult to control.

Frequently medications sold as “traditional medication” are not purely medicinal, an analysis of what ingredients appear in medications revealed a multitude of poisons and toxins that would not be allowed in medications for therapeutic use.

First described in the 1920’s where poorer populations were eating contaminated foods(white flour/poorly prepared)

Toxic compound is Pyrrolizidine Alkaloids(commonly found in plants all over the SA countryside and common in traditional medicine)

Results in portal hypertension and massive ascites

May present acutely(in a younger patient when the dose rapidly exceeds dangerous levels)

May present chronically with bleeding varices and increased pressure in the hepatic portal vein)

Prevention going forward?

Public engagement

Education and awareness for traditional healers and the public

Public Health Issues inEM Mike McCaul

Mike took us through the approach to the creation of a South African Clinical Practice Guideline (CPG). In SA there are numerous public health issues in EM especially with regard to Pre-hospital care. Call to create a clinical practice guideline was made in 2016 by AFEM, the aim was to look at >1000 recommendations for EM, with a major shift from protocol-based care to practice and patient based care.

The team Mike was involved in aimed to determine the perception of guideline dissemination and implementation in SA, looking at providers in all qualifications, two phases of the study were planned.

The first part of the study looked at the filter through which paramedics viewed the guidelines. Paramedics were influenced by previous CPG exposure and experience (paramedics were not sure what CPG’s meant and what the point was). Expectations included being empowered , and creation of a clear career pathway. Communication and methods for the communication of the CPG’s definitely indicated a lack of trust in the leadership and stakeholders in the system.

The thing that defines Critical Care for EMS is spagetti… “Dynamic comprehensive care of the patient with an acute or chronic illness needing transportation”
The challenge with an improving healthcare system, sicker patients are staying alive for longer, and the management of these patient is getting more and more complex.

Critical Care retrieval is becoming more about escalating care and managing the incredibly sick patient from an already high level of care to another possibly even higher level of care, in a moving environment, with even more challenges than we ever expected.

Transportation of the critical care patient MUST be either an upgrade in care, or continuation of care at the level at which the patient is currently managed. If we have all the fancy toys and vents, and pumps and ecmo… who is or should be managing the process? Internationally combination teams appear to be the standard, in Africa, the resources are again limited, we are often limited to multi-system approach to the transportation.
So who should be doing these transfers? THE NERD… the one who has done the additional work, reading, practical skill acquisition.

Load and go for these incredibly sick patients is probably NOT the best approach to management, the critical care patient is a completely different kettle of fish… Equipment must be specialised to account for the sick patient, we cannot be downgrading the level of care for transportation to upgrade for additional level of care in another facility.

So the bottom line for retrieval and out of hospital critical care in South Africa is clearly going to be a challenge, change is inevitable and in doing so we are going to have to challenge some established practice. Change is coming, it’s going to be good, but at times it will be tough.

Final thoughts from day 1
We’ve put this blog post together using the ‘Papers’ function on Dropbox. It’s a way of co-creating content in real time and seems to work really well for blogging as it handles the embedding of different media really easy. If you want to know more follow this link.

Thanks to Kayleigh, Kyleigh, Jen, Lucy, Willem, Lara, Alan, Manda, Jo and others who have made this blog post by writing or tweeting info.

So after a very busy day 1 we are off into the bush for a Braai. Simon is not entirely sure what this is, but is hoping for lots of vegetarian options…..or maybe we should follow this delegate

Co-creation

This blog and the other 2 in the EMSSA series were cocreated by a range of authors. Apologies if I’ve missed anyone! By co-created we mean that we all logged into the same online document and wrote the blogs as they happened. We used the Papers function on Dropbox. This appeared to work really well for capturing the conference narrative. Thanks to all.